Craniosacral Therapy, Osteopathic Manipulation, and Osteopathic Manipulative Treatment

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1 Easy Choice Health Plan, Inc. Harmony Health Plan of Illinois, Inc. Missouri Care, Inc. Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Plans of New Jersey, Inc. WellCare Health Insurance of Arizona, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc. WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc. WellCare of Ohio, Inc. WellCare of South Carolina, Inc. WellCare of Texas, Inc. WellCare Prescription Insurance, Inc. Windsor Health Plan for Medicare Advantage Part D Windsor Rx Medicare Prescription Drug Plan Craniosacral Therapy, Osteopathic Manipulation, and Osteopathic Manipulative Treatment Policy Number: Original Effective Date: 9/3/2009 Revised Date(s): 9/3/2010; 9/1/2011; 10/4/2012; 10/3/2013 DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult for list of current LOBs. APPLICATION STATEMENT The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

2 BACKGROUND Craniosacral Therapy Craniosacral therapy is a noninvasive osteopathic technique that involves the therapist touching the patient to detect pulsations and rhythms of flow of cerebrospinal fluid (CSF). The therapist then gently works with the skull and spine, with the goal to effect release of potential restrictions to the flow of CSF, without the use of forceful physical manipulation. Practitioners in this field use craniosacral therapy for a variety of musculoskeletal and general medical conditions. Although craniosacral therapy is a relatively new diagnostic and treatment procedure, its foundations reach back to the early 1900s, when William Sutherland, an osteopathic physician, disputed the belief that cranial bones were immobile. Sutherland developed cranial therapy, which is manipulation of the cranial bones to relieve a symptom or problem. Sutherland's cranial therapy is also based on a connection of the cranium to the sacrum via the dura. In the mid-1970s, John Upledger, also an osteopathic physician, reported the detection of a craniosacral rhythm that he believed to be the pulse of flow of the cerebrospinal fluid. Upledger went on to develop craniosacral therapy, which does not involve manipulation, but rather involves a reported detection of the craniosacral rhythm around the body and synchronization of the craniosacral rhythm between the cranium and the sacrum. Providers of craniosacral therapy claim that the light touches of the skull and spine performed during a craniosacral session can remove restrictions to the flow of cerebrospinal fluid, and thereby improve symptoms or problems for a wide variety of medical conditions. Craniosacral therapy, also called cranial osteopathy and cranial treatment, as developed by Sutherland, is taught to all osteopathic physicians; however, not all osteopathic physicians use the techniques in their practice. Craniosacral therapy, as developed by Upledger, is taught through the Upledger Institute to lay people, osteopathic physicians, chiropractors, dentists, physical therapists, and other licensed healthcare workers. Upledger is now in the process of obtaining a trademark for the name Upledger CranioSacral Therapy. The American Osteopathic Association (AOA) is the federally recognized body charged with approval of certifying boards within the osteopathic medical profession. The AOA has chartered the American Osteopathic Board of Neuromusculoskeletal Medicine; this certifying Board administers written, oral and practical examinations which include items relating to osteopathy in the cranial field and cranial osteopathy. Osteopathic Manipulative Treatment (OMT) Osteopathic manipulative treatment (OMT) involves using the hands to diagnose, treat, and prevent illness or injury by moving the muscles and joints using techniques that include stretching, gentle pressure and resistance. OMT is used to ease pain, promote healing and increase overall mobility. OMT is often used to treat muscle pain as well as asthma, sinus disorders, carpal tunnel syndrome, migraines and menstrual pain. ( 1 AOA, 2012). The American College of Physicians and the American Pain Society (ACP/APS) published a joint clinical guideline for the diagnosis and treatment of low back pain; spinal manipulation is recommended for patients who do not improve with self-care options (Chou & et al., 2007). Of note, the recommendation is characterized as weak and is based on moderate quality evidence. Spinal manipulation is recommended along with a number of other nonpharmacological therapies, and osteopathic manipulation is not specified by these guidelines. In 2010, the AOA published guidelines for osteopathic manipulative treatment for patients with low back pain based on a meta-analysis of six randomized controlled trials ( 1 AOA, 2010). They offered a strong recommendation that OMT be utilized by osteopathic physicians as a primary therapy for patients with a diagnosis of somatic dysfunction related to low back pain. They note that the diagnosis of somatic dysfunction entails a focal or complete history and physical examination, including an osteopathic structural examination that provides evidence of asymmetrical Clinical Coverage Guideline page 2

3 anatomical landmarks, restriction or altered range of motion, and palpatory abnormalities of soft tissues. They state that OMT for somatic dysfunction should be utilized after other potential causes of low back pain are ruled out or considered improbable by the treating physician. POSITION STATEMENT Craniosacral therapy administered by a therapist or provider is considered experimental and investigational for all indications. Osteopathic manipulation (OM) or osteopathic manipulative treatment (OMT) is a covered benefit for all indications. OMT must be performed by a licensed osteopathic practitioner with appropriate training as outlined by the American Osteopathic Association*. * For AOA criteria, see and the National Board of Osteopathic Medical Examiners ( Providers may also refer to HS 217 : Chiropractic Services. CODING Craniosacral Therapy Non-Covered CPT Codes for Craniosacral Therapy Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Unlisted Therapeutic procedure, when billed for craniosacral therapy HCPCS Level II Codes - No applicable codes ICD-9-CM Procedure Codes - No applicable codes Draft 2013 ICD-10-PCS Codes - No applicable codes Non-Covered ICD-9-CM Diagnosis Codes for Craniosacral Therapy Non-Covered Draft 2013 ICD-10-CM Diagnosis Codes Craniosacral Therapy Osteopathic Manipulation (OMT) Covered CPT Codes for OM or OMT Osteopathic manipulative treatment (OMT) HCPCS Level II Codes - No applicable codes ICD-9-CM Procedure Codes - No applicable codes Draft 2013 ICD-10-PCS Codes - No applicable codes Clinical Coverage Guideline page 3

4 Non-Covered ICD-9-CM Diagnosis Codes for Craniosacral Therapy Covered ICD-9-CM Diagnosis Codes for OM or OMT Asthma Carpal tunnel syndrome Lumbago Migraine Dysmenorrhea Myalgia and myositis, unspecified Other diseases of nasal cavity and sinuses Covered Draft 2013 ICD-10-CM Diagnosis Codes for OM or OMT J34.89 Unspecified disorders of nose and nasal sinuses J J Asthma G G56.02 Carpal tunnel syndrome G G Migraine M54.5 Low Back Pain M60.9 Myositis, unspecified M79.1 Myalgia N94.6 Dysmenorrhea, unspecified *Current Procedural Terminology (CPT ) 2013 American Medical Association: Chicago, IL. REFERENCES Peer Reviewed 1. Christine, D.C. (2009). Temporal bone misalignment and motion asymmetry as a cause of vertigo: the craniosacral model. Alternative Therapies in Health and Medicine, 15(6), Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J.T., Shekelle, P., & et al. (2007). Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), Hayes Directory. (2011, February 23). Osteopathic manipulative treatment (OMT) for back pain [updated on January 25, 2013]. Retrieved from 4. Hayes Directory. (2009). Craniosacral therapy [updated on March 7, 2013]. Retrieved from Government Agencies, Professional and Medical Organizations 1. 1 American Osteopathic Association. (2013). Licensing of osteopathic physicians. Retrieved from American Osteopathic Association. (2013). Osteopathic manipulative treatment. Retrieved from 3. American Osteopathic Association. (2010). Practice guideline for osteopathy in the cranial field. Retrieved from 4. American Cancer Society. (2011, March 7). Craniosacral therapy. Retrieved from 5. National Board of Osteopathic Medical Examiners. (2012). Candidates. Retrieved from Clinical Coverage Guideline page 4

5 MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Action 10/3/2013 Approved by MPC. No changes. 10/4/2012 Approved by MPC. Tabled from 9/6/2012 MPC. Inserted Osteopathic Manipulative Treatment in name. Expanded Background section. Included professional statements; AOA guideline with respect to who certifies practitioners. Four new references added. Revisions do not impact coverage; remains E/I. 12/1/2011 New template design approved by MPC. 9/1/2011 Approved by MPC. Clinical Coverage Guideline page 5